Inspection Reports for The Brentwood Senior Living
6920 SW Lee Blvd, Lawton, OK 73505, United States, OK, 73505
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 20, 2025, was a license renewal and had no deficiencies. Earlier inspections showed a mix of results, including substantiated deficiencies related to staff training and resident supervision, as well as issues with assessments, medication administration, and documentation. Complaint investigations generally found no deficiencies or unsubstantiated allegations, except for one substantiated case in October 2023 involving failure to maintain call light systems and resident checks, which resulted in immediate jeopardy that was later removed after corrective actions. No fines, license suspensions, or enforcement actions were listed in the available reports. The facility’s inspection history shows improvement over time, with the most recent survey free of deficiencies following earlier challenges.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
2.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
38 residents
Based on a February 2024 inspection.
Occupancy over time
Inspection Report
Renewal
Capacity: 90
Deficiencies: 0
Date: Feb 20, 2025
Visit Reason
This document serves as the renewal license for The Brentwood Senior Living, an assisted living center located in Lawton, Oklahoma.
Findings
The document certifies that Lawton Oklahoma Senior Living, LP is licensed to conduct and maintain an assisted living center with a maximum capacity of 90 beds. No deficiencies or findings are noted in this license renewal document.
Report Facts
Maximum licensed capacity: 90
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Date: Feb 15, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on allegations that the facility failed to assess and intervene for residents with changes in condition, failed to provide adequate housekeeping services, and failed to ensure water availability and comfortable room temperatures during a water outage.
Complaint Details
Two complaint investigations (#OK00062135 and #OK00062320) were conducted on 02/15/2024. Allegations included failure to assess residents in distress, inadequate housekeeping, admission of residents above level of care, and failure to ensure water availability and comfortable room temperatures during outages. No deficiencies were cited.
Findings
The complaint investigations found no deficiencies. Observations, interviews, and record reviews indicated that residents received appropriate care, staffing was adequate, housekeeping services were provided, and water supply and accommodations during outages were managed according to regulations.
Report Facts
Facility Census: 38
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 3
Date: Oct 18, 2023
Visit Reason
A complaint investigation was conducted due to allegations that the facility failed to ensure adequate supervision to prevent falls, failed to ensure call lights were working, and failed to ensure residents were checked every one to two hours when call lights were not working.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to ensure call lights were working, failed to ensure residents were checked every one to two hours, and failed to notify residents and families when call lights were not working. Immediate Jeopardy was identified related to neglect in supervision and failure to check residents every two hours. The Immediate Jeopardy was removed after corrective actions were implemented.
Findings
The investigation found that the facility failed to have a written statement of services related to a life alert pendant for one resident, failed to ensure residents were checked every two hours, resulting in an unwitnessed fall and prolonged time on the floor for one resident, and failed to maintain a working call light system. Immediate Jeopardy was identified but later removed after staff in-service and corrective actions. The facility was found to have actual harm with potential for more than minimal harm due to neglect in supervision and call light maintenance.
Deficiencies (3)
Facility failed to have a written statement of services provided related to a life alert pendant for one resident.
Facility failed to ensure residents were checked every two hours, resulting in an unwitnessed fall and prolonged time on the floor for one resident.
Facility failed to maintain a working call light system for resident safety.
Report Facts
Residents: 44
Fall incident date: Oct 9, 2023
Fall incident time: 2200
Call light pendant fee: 15
Plan of correction completion date: Nov 30, 2023
Revisit date: Dec 27, 2023
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 21, 2022
Visit Reason
The inspection was conducted as a complaint investigation regarding an allegation that the facility failed to prevent destruction of medical records.
Complaint Details
Allegation: The facility failed to prevent destruction of medical records. The allegation was unsubstantiated (US) after investigation.
Findings
The investigation found the allegation to be unsubstantiated. No deficiencies were cited, and residents were observed to be well groomed with medical records and related documentation properly maintained.
Report Facts
Residents sampled: 5
Residents with bathing assistance records waiting to be filed: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Edmiaston | RN, BSN | Signed the report and involved in determination summary |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Date: Jun 13, 2022
Visit Reason
A complaint survey was conducted at The Brentwood Senior Living on June 13, 2022, following allegations related to infection control and qualified personnel performing nursing care.
Complaint Details
Two allegations were investigated: (1) failure to have and/or implement an effective infection control program (unsubstantiated), and (2) failure to have qualified personnel performing nursing care (substantiated).
Findings
The investigation substantiated deficient practice related to the activity director performing personal care without proper training or certification, specifically providing manicures and pedicures to residents. No deficient practice was found regarding the infection control program. The facility was required to submit a plan of correction.
Deficiencies (1)
The center failed to ensure an activity director was not performing personal care to residents without training, a competency evaluation, and a current nurse aide certification.
Report Facts
Residents present: 59
Residents scheduled for nail care: 4
Deficiency cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shelia Williamson | RN, Clinical Health Facility Surveyor | Signed the investigative report dated 06/14/2022. |
| Linda Climer | Administrator | Reported census and confirmed activity director's role and lack of certification. |
| Katie Stagner | Enforcement Reviewer/Analyst | Signed the letter confirming correction of deficiencies. |
| Tempal Killman | Administrative Assistant II, Long Term Care Enforcement Division | Signed letter accepting plan of correction. |
Inspection Report
Re-Inspection
Deficiencies: 12
Date: Apr 28, 2022
Visit Reason
A relicensure survey was conducted in conjunction with complaint investigations at The Brentwood Senior Living from April 25, 2022 through April 28, 2022.
Complaint Details
The complaint investigation included allegations that the center failed to provide adequate care and services, failed to ensure residents' property was not removed, failed to ensure medications were administered safely according to physicians' orders, and failed to ensure resident medications were not misappropriated. All allegations were unsubstantiated.
Findings
The survey identified multiple deficiencies including failure to conduct competency skills evaluations for direct care staff, failure to obtain current nurse aide certifications, failure to validate certified medication aide skills, incomplete comprehensive resident assessments, lack of personal interviews for assessments, failure to obtain RN monthly medication reviews, lack of CPR/First Aid training documentation for staff, failure to obtain signed physician orders and code status for recent admissions, improper oxygen cylinder storage, failure to submit incident reports for resident falls, and medication administration errors including timing and observation of swallowing.
Deficiencies (12)
Failed to conduct competency skills evaluations for 15 direct care staff members.
Failed to obtain current nurse aide certification for one of seven sampled CNAs.
Failed to validate certified medication aide skills prior to medication administration for three CMAs and failed to review annual competencies for five CMAs.
Failed to complete comprehensive assessments for four residents and failed to promptly complete significant change assessment for one resident.
Failed to coordinate assessments with a registered nurse or physician for one resident.
Failed to conduct personal interviews between the resident and the person completing the assessment form for three residents.
Failed to obtain evidence of RN monthly medication reviews for all 63 residents.
Failed to submit evidence of CPR/First Aid training for five direct care staff members.
Failed to promptly obtain signed physician orders including medications and code status for two recent admissions and failed to properly store oxygen cylinders for one resident.
Failed to submit two incident reports related to falls to the Oklahoma State Department of Health for two residents transferred to hospital.
Failed to administer medications within the one hour window for one resident and failed to observe swallowing of medications for one resident.
Failed to coordinate services with a third-party provider related to bathing assistance for one resident receiving home health services.
Report Facts
Direct care staff lacking competency skills evaluations: 15
Sampled CNAs lacking current certification: 1
Sampled CMAs lacking skill validation: 3
Sampled CMAs lacking annual competency review: 5
Residents lacking comprehensive assessment: 4
Residents lacking personal interview for assessment: 3
Residents lacking RN monthly medication reviews: 63
Direct care staff lacking CPR/First Aid training documentation: 5
Residents with delayed signed physician orders: 2
Residents with improper oxygen cylinder storage: 1
Residents with unreported incident reports: 2
Residents with medication administration errors: 2
Residents with bathing assistance coordination failure: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Climer | Administrator | Named in relation to facility management and plan of correction submissions. |
| Donna Ahlborn | RN MSN Clinical Health Facility Surveyor | Signed complaint investigation reports. |
| Lisa Calvin | Enforcement Reviewer/Analyst | Signed enforcement and revisit letters. |
| Tempal Killman | Administrative Assistant II | Signed acceptance letter for plan of correction. |
Inspection Report
Renewal
Capacity: 90
Deficiencies: 0
Date: Apr 21, 2021
Visit Reason
This document is a license renewal issued to Lawton Oklahoma Senior Living, LP for The Brentwood Senior Living assisted living center.
Findings
The license certifies that the facility is authorized to conduct and maintain an assisted living center with a maximum capacity of 90 beds. The license is effective from 02/20/2021 and expires on 02/19/2022.
Report Facts
Maximum licensed beds: 90
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Date: Mar 5, 2021
Visit Reason
The inspection was conducted as a complaint investigation in conjunction with a COVID-19 Special Focus Infection Control Survey to determine compliance with infection prevention and control practices related to complaint OK #56539.
Complaint Details
Complaint #OK00056539 included allegations that the center failed to ensure care was provided as contracted and failed to ensure medications were administered as ordered by the physician. Both allegations were unsubstantiated (US).
Findings
The investigation found no deficiencies; both allegations regarding care provision and medication administration were unsubstantiated. Staff were observed providing appropriate care and assistance, and residents reported no concerns.
Report Facts
Total residents: 40
Sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bobbi Bridges | RN, CHFS | Signed the determination summary and follow-up action report |
Inspection Report
Abbreviated Survey
Census: 45
Deficiencies: 0
Date: Dec 2, 2020
Visit Reason
The Oklahoma State Department of Health conducted a COVID-19 Special Focus Infection Control Survey to determine if the facility was in compliance with infection prevention and control practices related to COVID-19.
Findings
No deficiencies were cited during the COVID-19 Special Focus Survey conducted on December 2, 2020.
Report Facts
Total residents: 45
Inspection Report
Renewal
Capacity: 90
Deficiencies: 0
Date: Feb 20, 2020
Visit Reason
This document serves as a renewal license for The Brentwood Senior Living Assisted Living Center, authorizing the facility to continue operations.
Findings
The license was issued pursuant to Oklahoma statutes and state board of health regulations, confirming the facility meets requirements for renewal.
Report Facts
Maximum licensed beds: 90
Inspection Report
Renewal
Census: 50
Deficiencies: 3
Date: Nov 13, 2019
Visit Reason
A State Licensure survey was conducted at The Brentwood Senior Living assisted living center from November 12 to November 13, 2019, as part of the renewal/licensure process.
Findings
Deficiencies were identified related to assessment timeframes, nursing services, and coordination of care. The facility failed to complete a significant change assessment for a resident and failed to ensure blood pressure readings were reported to the physician. The plan of correction was accepted and a follow-up revisit was scheduled.
Deficiencies (3)
Failed to complete a significant change assessment for 1 sampled resident who experienced a significant change in condition.
Failed to ensure blood pressure readings were reported to the physician for 1 sampled resident with blood pressure parameters.
Failed to coordinate home health services to notify the physician of abnormal blood pressure readings for 1 sampled resident.
Report Facts
Census: 50
Deficiencies cited: 3
Follow-up revisit date: Feb 6, 2020
Census at follow-up: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Climer | Administrator | Named as facility administrator in relation to the survey and plan of correction |
| Sue Davis | Enforcement Coordinator / Long Term Care Enforcement Reviewer | Signed enforcement and acceptance letters related to the survey |
Inspection Report
Renewal
Capacity: 90
Deficiencies: 0
Date: Mar 15, 2019
Visit Reason
This document is a license renewal issued to Lawton Oklahoma Senior Living, LP to conduct and maintain an Assisted Living Center.
Findings
The license renewal certifies that the facility is authorized to operate with a maximum capacity of 90 beds, effective from 02/20/2019 to 02/19/2020.
Report Facts
Maximum licensed beds: 90
Viewing
Loading inspection reports...
